Predictive factors for time to remission and recurrence in patients treated for acute mania: health outcomes of manic episodes (HOME) study

Effects of Lithium Combined with Second-Generation Antipsychotics for the Treatment of Manic Episodes in Patients with Bipolar Disorder: A Naturalistic Study in China

OBJECTIVE

To explore the therapeutic effects of lithium combined with second-generation antipsychotics (SGAs) of quetiapine, clozapine, olanzapine, and risperidone for the treatment of manic episodes in patients with bipolar disorder (BD) to guide the selection of medications.

METHODS

We examined the case data of patients with BD who experienced manic episodes and were hospitalized in a Class 3A Psychiatric Hospital in Anhui Province from January 2015 to October 2019. The enrolled patients were rated using the Bech-Rafaelsen Mania Rating Scale (BRMS) before and after treatment, and relevant adverse effects were monitored.

RESULTS

Analysis of the collected case data of 182 patients showed significant differences in the BRMS scores on admission and at discharge of patients treated with lithium combined with each SGA. The chi-square test showed no obvious difference in the final therapeutic effects of lithium combined with each of the four SGAs (χ² = 7.365, P = 0.146). However, there were differences in the incidence of adverse effects (χ ² = 10.604, P = 0.014) and remission rate after 2 weeks of treatment (χ² = 10.174, P = 0.017). Logistic regression analysis revealed that the incidence of adverse effects was related to the length of stay in hospital and clozapine treatment. The remission rate after 2 weeks was associated with the length of stay in hospital, clozapine treatment, and age of onset.

CONCLUSION

Lithium combined with SGAs (quetiapine, clozapine, olanzapine, and risperidone) effectively improves the manic symptoms of patients with BD who experience manic episodes. Lithium combined with quetiapine for the treatment of bipolar manic episode has advantages with respect to the speed of effective and incidence of adverse effects.

Atypical antipsychotic adherence is associated with lower inpatient utilization and cost in bipolar I disorder

AIMS

This study explored the association between medication adherence to oral atypical antipsychotics (AAP) and both psychiatric hospitalization and associated costs in bipolar I disorder (BD-I) in a real-world setting.

MATERIALS AND METHODS

This retrospective study used the Truven Health MarketScan Medicaid, Commercial, and Medicare Supplemental Claims Databases. Adults were identified if they had BD-I and initiated an AAP treatment during the study identification period (July 1, 2015-June 30, 2016 for Medicaid, July 1, 2015-March 31, 2016 for Commercial and Medicare Supplemental) and had ≥6-month continuous enrollment before (baseline) and after (follow-up) the first day of treatment. Medication adherence was measured by the proportion of days covered (PDC) and grouped as: fully-adherent (PDC ≥80%), partially-adherent (40% ≤ PDC <80%), and non-adherent (PDC <40%). Logistic and linear regression models were conducted to estimate the risk of psychiatric hospitalization and costs during the 6-month follow-up period.

RESULTS

The final sample consisted of 5,892 (32.0%) fully-adherent, 4,246 (23.1%) partially-adherent, and 8,250 (44.9%) non-adherent patients. The adjusted rate of psychiatric hospitalization during the follow-up period was lower in the fully-adherent (6.0%) vs partially- (8.3%) or non-adherent (8.8%) groups (p < 0.001). Using the fully-adherent cohort as the reference group, the odds of psychiatric hospitalization were significantly higher for the partially-adherent (OR = 1.42; 95% CI = 1.23-1.64) and non-adherent (1.51; 1.33-1.71) cohorts. The mean adjusted psychiatric hospitalization cost over 6 months among hospitalized patients was lower for the fully-adherent cohort ($11,748), than the partially-adherent ($15,051 p = 0.002) or non-adherent cohorts ($13,170, not statistically significant).

LIMITATIONS

The medication adherence measures relied on prescription claims data, not actual use.

CONCLUSIONS

In the treatment of BD-I, better medication adherence to AAP was associated with fewer psychiatric hospitalizations. Among hospitalized patients, fully-adherent patients had statistically significantly lower psychiatric costs than partially-adherent ones. These findings suggest that improving adherence to AAP in BD-I may be a valuable goal from both clinical and economic perspectives.

Factors affecting time to remission for inpatients with bipolar mania - A naturalistic Taiwanese study

BACKGROUND

Bipolar disorder is a complicated and chronic mental disorder. This study investigated factors affecting time to remission for inpatients with bipolar mania after 4 weeks of acute treatment.

METHODS

This naturalistic study recruited inpatients with bipolar mania for acute treatment. Symptom severity was assessed using the Young Mania Rating Scale (YMRS) at weeks 0, 1, 2, 3, and 4. Patients were included if they had had assessments at weeks 0 and 1 Remission was defined as an YMRS score ≤ 12. The Cox regression analysis was used to analyze factors associated with time to remission after 4 weeks of acute treatment.

RESULTS

Four hundred and forty-nine patients entered the analysis. Seventy-one of the 449 subjects (15.8%) reached symptomatic remission within 4 weeks of acute treatment. Using forward multivariate Cox regression analysis, comorbid substance use disorders, earlier age at onset, and greater manic symptom severity at baseline found to be statistically significant predictors of a longer time to reach remission after 4 weeks of treatment.

LIMITATIONS

As a retrospective chart review and naturalistic design, placebo effect and potentially confounding factors such as the possibility of missing records may have limited our results.

CONCLUSIONS

Early identification and intervention with integrated therapy is considered to shorten time to remission for patients at high risk of poor treatment outcome. More studies are needed in other real-world settings to generalize our results.

The impact of affective temperaments on clinical and functional outcome of Bipolar I patients that initiated or changed pharmacological treatment for mania

BACKGROUND

Affective temperaments have been shown to impact on the clinical manifestations and the course of bipolar disorder. We investigated their influence on clinical features and functional outcome of manic episode.

METHOD

In a naturalistic, multicenter, national study, a sample of 194 BD I patients that initated or changed pharmacological treatment for DSM-IV-TR manic episode underwent a comprehensive evaluation including briefTEMPS-M, CTQ, YMRS, MADRS, FAST, and CGI-BP. Factorial, correlation and comparative analyses were conducted on different temperamental subtypes.

RESULTS

Depressive, cyclothymic, irritable and anxious temperaments resulted significantly correlated with each other. On the contrary, hyperthymic temperament scores were not correlated with the other temperamental dimensions. The factorial analysis of the briefTEMPS-M sub-scales total scores allowed the extraction of two factors: the Cyclothymic-Depressive-Anxious (Cyclo-Dep-Anx) and the Hyperthymic. At final evaluation Dominant Cyclo-Dep-Anx patients reported higer scores in MADRS and in CTQ emotional neglect and abuse subscale scores than Dominant Hyperthymic patients. The latter showed a greater functional outcome than Cyclo-Dep-Anx patients.

CONCLUSIONS

Affective temperaments seem to influence the course of mania. Childhood emotional abuse and neglect were related to the cyclothymic disposition. Cyclothymic subjects showed more residual depressive symptoms and Hyperthymic temperament is associated with a better short-term functional outcome.

Predictors of recurrence during long-term treatment of bipolar I and II disorders. A 4 year prospective naturalistic study

BACKGROUND

Despite the large number of treatments available for bipolar disorder (BD), more than one half of patients have a recurrence within 2 years, and over 90% experience at least one additional affective episode during their lifetime.

METHODS

The aim of this study was to test the impact of a number of demographic and clinical features on the risk to recurrence in a real- word representative sample of 266 outpatients with BD-I or II treated in a naturalistic setting during a 4-years-follow-up period.

RESULTS

We found that the number of episodes per year after study entry, compared to the number of episodes per year before study entry,significantly decreased and that about one third of patients had no recurrences during the observation period. The length of follow-up and the number of previous episodes, mainly depressive, predicted the risk of recurrence, while female gender, higher age at intake, and a higher frequency of past mixed episodes predicted a higher frequency of recurrences.

LIMITATIONS

The study had some limitations to consider: i.e. the risk of poor reliability of information on the previous course of illness or the naturalistic treatment during the follow-up.

CONCLUSIONS

Our study suggests that (a) an evidence-based long-term treatment, with regular follow-up visits could improve the course of disease and prognosis; (b) clinicians should carefully consider the presence of a high number of mixed episodes, to provide more targeted treatment strategies; (c) an appropriate use of antidepressants in selected patients did not worsen the course of illness.

Predictors of a Shorter Time to Hospitalization in Patients with Bipolar Disorder: Medication during the Acute and Maintenance Phases and Other Clinical Factors

Objective

The present study was conducted to compare the effects of pharmacological treatments during the acute and maintenance phases of mood episodes, sociodemographic, and clinical characteristics between a shorter time to hospitalization group (<12 months) and a longer time to hospitalization group (≥12 months).

Methods

The discharge medication for the first hospitalization was considered the acute treatment and the medication used during the week prior to the second hospitalization at the outpatient clinic was considered the maintenance treatment. Additionally, the charts were reviewed to examine a variety of demographic and clinical characteristics.

Results

Patients in the shorter time to hospitalization group were more likely to be unmarried and/or unemployed, have had a previous hospital admission for a mood episode, and have used antidepressant during the acute phase than those in the longer time to hospitalization group. Patients in the shorter time to hospitalization group were also less likely to use olanzapine, serotonin-norepinephrine reuptake inhibitors, or mood stabilizer monotherapy as a maintenance treatment than were patients in the longer time to hospitalization group.

Conclusion

Predictors for shorter time to hospitalization were associated with number of previous hospital admissions for a mood episode, being unmarried and/or unemployed, and antidepressant use during the acute phase.

Early Improvement Predicts Treatment Outcomes for Patients With Acute Mania: A Naturalistic Study in Taiwan

BACKGROUND

Bipolar disorder is a serious mental disorder. This study investigated whether early improvement at week 1 or 2 could predict treatment outcomes at week 4 in clinical populations with acute mania.

METHODS

We conducted a naturalistic study, recruiting inpatients with bipolar mania for acute treatment. Symptom severity was assessed using the Young Mania Rating Scale (YMRS) at weeks 0, 1, 2, 3, and 4. Early improvement was defined as a reduction in the YMRS score of at least 20% or 25%, assessed at weeks 1 and 2. Response was defined as a reduction of 50% or more in the YMRS score, and remission was defined as an end-point YMRS score of 12 or less. Receiver operating characteristic curves were used to determine whether week 1 or week 2 had better discriminative capacity. Sensitivity, specificity, and predictive values were calculated for the different definitions of early improvement.

RESULTS

Of the 350 patients, 32.9% (n = 115) and 16.6% (n = 58) of the subjects were classified as responders and remitters at week 4, respectively. Early improvement at week 2 showed better discriminative capacity, with areas under the receiver operating characteristic curve greater than 0.8. It had high sensitivity and high negative predictive value for 2 cutoffs in predicting response and remission.

CONCLUSIONS

Relatively lower response and remission rates were observed. Response and remission could be predicted by early improvement at week 2, whereas patients without early improvement were unlikely to reach response and remission at week 4.

A 2-year follow-up study of discharged psychiatric patients with bipolar disorder

This study investigated medication compliance, disease recurrence and the recovery of social function in discharged psychiatric patients with bipolar disorder. A 2-year follow-up was conducted on all patients with bipolar disorder, who were hospitalized in our psychiatric department between June 2010 and May 2011. Risk factors for recurrence were analyzed based on a self-designed questionnaire. Of the 252 patients in the study, 210 had complete information (83.3%) for the 2-year follow-up: 170 cases of bipolar I disorder and 40 cases of bipolar II disorder. The 1-year and 2-year full-compliance rates were 41.0% and 35.7%, respectively. The 1-year and 2-year recurrence rates were 42.4% and 61.0%, respectively. Statistically significant differences in rates were found between the bipolar subtypes for 1-year full compliance, 1-year non-compliance, 2-year recurrence, and 2-year readmission. Logistic regression identified different sets of independent variables that were risk factors for recurrence, and protective factors for recurrence at 1 year and 2 years after hospital discharge. The results of the follow-up indicated that the situation of patients with bipolar disorder after discharge is not optimistic, because of high recurrence rates, high non-compliance rates and low recovery rates. Clinical and social experts should pay more attention to the situation.

Young Mania Rating Scale: how to interpret the numbers? Determination of a severity threshold and of the minimal clinically significant difference in the EMBLEM cohort

The aim of this analysis was to identify Young Mania Rating Scale (YMRS) meaningful benchmarks for clinicians (severity threshold, minimal clinically significant difference [MCSD]) using the Clinical Global Impressions Bipolar (CGI-BP) mania scale, to provide a clinical perspective to randomized clinical trials (RCTs) results. We used the cohort of patients with acute manic/mixed state of bipolar disorders (N = 3459) included in the European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM) study. A receiver-operating characteristic analysis was performed on randomly selected patients to determine the YMRS optimal severity threshold with CGI-BP mania score ≥ "Markedly ill" defining severity. The MCSD (clinically meaningful change in score relative to one point difference in CGI-BP mania for outcome measures) of YMRS, was assessed with a linear regression on baseline data. At baseline, YMRS mean score was 26.4 (±9.9), CGI-BP mania mean score was 4.8 (±1.0) and 61.7% of patients had a score ≥ 5. The optimal YMRS severity threshold of 25 (positive predictive value [PPV] = 83.0%; negative predictive value [NPV] = 66.0%) was determined. In this cohort, a YMRS score of 20 (typical cutoff for RCTs inclusion criteria) corresponds to a PPV of 74.6% and to a NPV of 77.6%, meaning that the majority of patients included would be classified as severely ill. The YMRS minimal clinically significant difference was 6.6 points.

A double-blind, randomized, placebo-controlled trial of adjunctive ramelteon for the treatment of insomnia and mood stability in patients with euthymic bipolar disorder

BACKGROUND

Abnormalities in circadian rhythms are prominent features of bipolar disorder. Disrupted circadian rhythms are associated with an increased risk of relapse in bipolar disorder. Normalizing the circadian rhythm pattern of bipolar patients may improve their sleep and lead to fewer mood exacerbations. This study evaluated adjunctive ramelteon for the treatment of insomnia and mood stability in euthymic bipolar patients.

METHODS

Participants with euthymic bipolar disorder and sleep disturbances were randomized to receive adjunctive ramelteon or placebo in addition to their regular psychiatric medications for up to 24 weeks or until they experienced a relapse (defined as a depressed or manic event).

RESULTS

83 participants were randomized to receive ramelteon (n=42) or placebo (n=41). Forty participants relapsed (48.2%). Cox regression analyses indicated that participants who received ramelteon (odds ratio 0.48, p=.024) were less likely to relapse. Kaplan Meier curves also indicated longer median survival times in the ramelteon group (Mdn=188 days) versus the placebo group (Mdn=84 days) X2(1)=5.33, p=.02. There were no serious adverse events in this study.

LIMITATIONS

This was a small study with only 83 participants. The one-week window of confirmed stability is shorter than time intervals used in other studies.

CONCLUSIONS

The present study shows that ramelteon was effective in maintaining stability for individuals with bipolar disorder. Patients treated with ramelteon were approximately half as likely to relapse as patients treated with placebo throughout the 24-week treatment period.

Long-term efficacy of quetiapine in combination with lithium or divalproex on mixed symptoms in bipolar I disorder

BACKGROUND

To evaluate quetiapine in patients with bipolar I disorder with mixed symptoms.

METHODS

Data from 2 studies (D1447C00126, D1447C00127) were pooled and mixed events analyzed separately. Patients received quetiapine (400-800mg/day) plus lithium/divalproex to achieve ≥12 weeks of clinical stability, followed by double-blind quetiapine (400-800mg/day) or placebo, plus lithium/divalproex, for up to 104 weeks. Primary endpoint was time to first mood event post-randomization.

RESULTS

The ITT population included 1326 patients, of whom 445 had a mixed episode at study entry, 219 received quetiapine plus lithium/divalproex, and 226 received placebo plus lithium/divalproex. Mood events were reported by fewer quetiapine-plus-lithium/divalproex than placebo-plus-lithium/divalproex-treated patients (21.0% vs 54.0%), and included mixed (6.4% vs 22.1%), pure manic (5.0% vs 13.3%), and pure depressed events (9.6% vs 18.6%). Hazard ratios (HR) for time to recurrence were longer for quetiapine plus lithium/divalproex than placebo plus lithium/divalproex for mixed (HR=0.23; 95% CI: 0.13-0.42; p<0.0001), pure manic (HR=0.30; 95% CI: 0.15-0.60; p=0.0007), and pure depressed events (HR=0.38; 95% CI: 0.22-0.64; p=0.0003). No new safety concerns were noted.

LIMITATIONS

The post hoc nature of the analyses as patients were not randomized according to index symptom status.

CONCLUSIONS

In stable patients with bipolar I disorder, quetiapine plus lithium/divalproex significantly increased time to recurrence of mood events versus placebo in patients with mixed symptoms at study entry and time to occurrence of mixed-mood events in patients with any mood episode at study entry.

Health care resource utilization and costs in a commercially insured population of patients with bipolar disorder type I and frequent psychiatric interventions

BACKGROUND

Bipolar disorder type I (BP-I) is one of the most expensive behavioral diagnoses in the United States. Characterizing patient populations that consume significant resources would be useful for designing and implementing additional resources and targeted interventions to reduce the costs of BP-I.

OBJECTIVE

This analysis compared the characteristics, health care resource utilization, and costs of commercially insured patients with BP-I (indicating a history of manic or mixed episodes) and frequent psychiatric interventions (FPIs) versus those without FPIs.

METHODS

This retrospective study used data from commercial insurance claims to identify adults with FPIs (≥2 clinically significant events [CSEs]) or without FPIs during a 12-month identification period (year 1). CSEs included emergency department (ED) visits or hospitalizations with a principal diagnosis of BP-I, the addition of a new medication to the observed treatment regimen, or a ≥50% increase in BP-I medication dose. Demographic and clinical characteristics were evaluated during the identification period, and health care resource utilization and costs were evaluated during a 12-month follow-up period (year 2).

RESULTS

Data from 7620 patients with FPIs and 11,571 without FPIs were included (women, 67.1% and 59.9%, respectively; P < 0.001). Of patients with FPIs in the identification period, 22.2% continued to have FPIs in the follow-up period. In the follow-up period, the group with FPIs had a greater proportion of patients with psychiatric-related inpatient hospitalizations (14.6% vs 2.8%) and ED visits (11.6% vs 2.7%) [corrected], a longer mean hospital length of stay (11.74% vs 8.24 days) [corrected], and greater adjusted mean psychiatric-related costs ($6617 vs $3276) and all-cause health care costs ($14,091 vs $9357) compared with the group without FPIs (all, P < 0.001). The risks for a psychiatric-related hospitalization and an ED visit during the follow-up period were significantly greater in the group with FPIs compared with the group without (odds ratios, 4.86 and 3.76, respectively; both, P < 0.01).

CONCLUSIONS

In this retrospective analysis, FPIs were associated with a greater number of FPIs during follow-up, ∼2-fold the psychiatric-related costs, and 1.5-fold the all-cause health care costs compared with no FPIs. These data highlight the economic burden of FPIs and the potential for health care cost reductions from improved management options in these patients.

Poor adherence to treatment associated with a high recurrence in a bipolar disorder outpatient sample

BACKGROUND

We analyzed the association of previous course-of-illness and other variables of clinical interest with a high frequency of both depressive or (hypo)manic episodes controlling for the effect of socio-demographic characteristics.

METHODS

A total of 108 outpatients with a DSM-IV diagnosis of bipolar disorder (BD) were recruited. A retrospective and naturalistic study was conducted to examine the number of affective episodes and their relationship with socio-demographic, clinical and course-of-illness variables, including adherence to medication, type of medication used and the use of addictive substances. The episode frequency was estimated as the number of "major instances" of depression, hypomania and mania during the illness. To classify the patients into two groups (higher and lower-episode frequency), we used the statistical criterion of median split. Results were analyzed with logistic regression models to control for the effects of potential confounders.

RESULTS

A high episode frequency (nine or more episodes) was associated with age (36-55years), delay in diagnosis, poor adherence to medication and current use of antipsychotic medication. In addition, a high frequency of manic episodes (four or more) was associated with female sex, age (>36years) and a manic onset of the illness, whereas a high frequency of depressive episodes (five or more) was associated with delay in diagnosis and poor adherence to medication.

LIMITATIONS

Cross-sectional study design.

CONCLUSIONS

Avoiding delay in diagnosis and enhancing treatment adherence might be important targets for reducing recurrences in BD.

The association of weight gain with mood symptoms and functional outcomes following a first manic episode: prospective 12-month data from the Systematic Treatment Optimization Program for Early Mania (STOP-EM)

OBJECTIVES

Up to 75% of patients with bipolar I disorder (BD-I) are overweight or obese. Obesity is associated with an increased liability for mood episodes in patients with established BD-I, but data from early in the illness are lacking. Obesity in the general population is also consistently associated with functional impairment, but the relationship between weight gain and functional outcomes in BD-I has received little attention.

METHODS

We measured rates of clinically significant weight gain (CSWG), defined as gaining ≥ 7% of baseline weight, over 12 months in 46 patients with BD-I who recently recovered from their first manic episode. We compared patients with and without CSWG for (i) the amount of time spent with mood symptoms, assessed using standard clinical rating scales and National Institute of Mental Health Life Charts, and (ii) functioning at 12 months, measured using the Multidimensional Scale of Independent Functioning (MSIF).

RESULTS

A total of 41% of patients (n = 19) experienced CSWG by 12 months. We did not detect an association between CSWG and the number of days with mood symptoms. Patients with CSWG had significantly poorer 12-month global functioning than those without CSWG [MSIF score = 2.26 (SD = 1.24) versus 1.74 (0.98); p = 0.011]. Functional impairment was independent of recent or current mood symptoms, which were entered as covariates in our analyses.

CONCLUSIONS

Weight gain may be an overlooked, but potentially modifiable, cause of functional impairment in BD-I. Clinicians should consider the possibility of weight gain when making the earliest treatment decisions in BD-I.

Twelve-month prospective, multinational, observational study of factors associated with recovery from mania in bipolar disorder in patients treated with atypical antipsychotics

OBJECTIVES

Atypical antipsychotic agents constitute one therapeutic approach for bipolar disorder. Since disease course and outcome are variable, further studies are needed to complement limited data supportive of clinical decisions at treatment initiation.

METHODS

This 12-month, prospective, observational study investigated factors associated with symptomatic remission (total YMRS score < or =12) and full clinical recovery (sustained reduction in CGI-BP-S overall score) in bipolar disorder during treatment with atypical antipsychotics (predominantly olanzapine, risperidone and quetiapine; alone or in combination with a psychotropic such as lithium or valproate) in actual clinical practice.

RESULTS

Amongst 872 enrolled and eligible patients, rates of symptomatic remission and full clinical recovery at 12 months were 93.0 and 78.5%, respectively. Of the baseline factors significantly (P< or =0.05) associated with symptomatic remission, the following categories were positively associated with a higher chance of symptomatic remission: Caucasian ethnicity; higher CGI-BP-S scores; family-dependent living; a previous manic episode; 1, 2 or > or =5 social activities; no work impairment; and being neither satisfied nor dissatisfied with life. Outpatient treatment and historically longer periods of mania were significantly positively associated with full clinical recovery.

CONCLUSIONS

While clinical status may also be associated with longer-term remission and recovery, factors relating to social functioning and quality of life are easily assessed and potentially modifiable. Such knowledge may aid physicians' clinical decisions regarding patients with bipolar mania treated with atypical antipsychotics.